CURRENT BOOKSFrom Madhouses to Modern Treatments

As a history of a major medical specialty and a major public health problem, Dr. Jeffrey Lieberman’s Shrinks: The Untold Story of Psychiatry raises some disturbing questions. The field of psychiatry is based on a patient’s history and behavior, though histories can be creative, and behavior is typically interpreted in the eyes of the beholders, often with their own agendas. Where is the science? In an age of laboratory tests, functional MRIs, genetic markers and even pathology slides, none exist for psychiatric diagnoses. We look, we listen and we try out medications, often based on a “best guess.” The current interventions, such as electroshock and transcranial stimulation, may be effective, but the underlying science remains elusive.

Lieberman chairs the psychiatry department at Columbia University School of Medicine and is eminently qualified to write this story. He has watched and participated in the evolution of the field from a Freudian-based psychoanalytic specialty to an intervention-based practice that can now identify and treat some of the most impaired people in our society.

Shrinksis divided into three parts: one historical, one on therapeutic advances, and one about the battle between the traditional Freudian ana-lysts and the new wave of psychiatrists.

The first part begins with a review of pseudoscience, fraud and greed. People who are aware that “something is not right” will often search for answers wherever they can, and when no good answers are forthcoming, they look for promises from people who are good salesmen with dubious credentials. Mesmer’s animal magnetism, Reich’s orgone accumulator, and Amen’s SPECT scans all offered promises of diagnosis and treatment that proved unfounded. The sole beneficiaries were the inventors themselves.

Sigmund Freud—a classically trained neurologist who studied under Jean-Martin Charcot, the founder of modern neurology—developed a theory of internal conflicts as the basis of mental illness. By slowly identifying these conflicts, much of the disturbed behavior could be treated or at least understood. This, of course, couldn’t apply to people with severe degrees of illness. They were left to the backup system, which consisted of mental institutions, i.e., the madhouses. Through the first half of the 20th century, those were the two major options.

Well-meaning but poorly understood therapies abounded. People with syphilis of the brain, known as general paresis of the insane, were noted to significantly improve after running a high fever, for any reason. A “cure” was proposed to give these patients malaria since once the fever subsided, the malaria could be treated with quinine. Transient improvement was noted in some patients, but often the therapy merely added one incurable disease on top of another.

A surgical technique to cure mental illness by cutting out a portion of the frontal lobe—the infamous Ice Pick surgery—was performed thousands of times, earning developer Egas Moniz a Nobel Prize in medicine. The result was a placid but hardly normal person.

Violent behavior—felt by some psychiatrists to be a focal neurologic condition related to temporal lobe epilepsy and amenable to localized surgery—was the basis of Michael Crichton’s novel The Terminal Man. Crichton took care of these patients while a medical student in Boston, and I inherited them when I arrived as the neurology resident. The procedure involved an implanted electrode that could be used as a micro-cautery to burn out the irritable focus. The patients became less violent but also passive and paranoid. Surgery certainly hasn’t given us an answer to mental illness. For a review of the thinking at that time, Violence and the Brain, by Vernon Mark and Frank Irvin, is still available.

Societies have always had outliers. The treatment of these people has varied, with some burned at the stake, some exiled, some shunted into religious orders and others merely locked up. The idea of locking up people for a behavioral abnormality, and not because of breaking a specific law, led to a strong antipsychiatry movement in the 1960s and 70s, led by a prominent psychiatrist named Thomas Szasz. His books The Myth of Mental Illness and Law, Liberty and Psychiatry were confrontational to the standard thinking at the time. As one of his students, I had to carefully distance myself from him when taking my oral boards in neurology and psychiatry. During the 1970s, psychiatry still had significant input from the psychoanalysts and traditionalists.

Psychiatry has evolved. With the development of medications for the most severe forms of mental illnesses, the need for locked institutions with up to 20,000 patients has passed. Of course, putting these people on the street under the care of community clinics, where they are largely unsupervised, means that a large portion of them no longer take their medications. Many homeless people would have been residents of the state hospitals in the past. Those hospitals were closed more for economic reasons than because better treatment was available in the community.

The historical section of Shrinks is a fascinating tale, though a little long on the details of Freud’s circle of professional friends and their often petty feuds. As most readers are not psychiatrists, these details seem unnecessary. More information as to what actually transpired in the madhouses during different eras might be more enlightening. “One Flew Over the Cuckoo’s Nest” is the only reference most of us have for those institutions. Having trained at one of the madhouses, Creedmoor State Hospital in New York, I could relate to psychiatric hospitals as alternative jails with no need for a judge or jury. The signature of a junior resident, whose first language was often not English, was enough to have you locked up for seven days. If two staff members signed off on it, you could be held for 30 days!

The second section of Shrinks—on advances in treatment over a relatively short period of time—is the core of the book. The ability to treat psychosis and severe depression has been lifesaving for a huge number of people. It has allowed people with significant mental illness to function independently and productively, which was unheard of in prior eras.

Modern psychiatry has identified post-traumatic stress disorder as a real illness and recognized severe depression as a potentially fatal disease. Diagnosis and treatment is the core of how medicine is practiced. Psychiatry is finally catching up. Modern medicines work more often than not, even if we don’t quite know how. They are safer than their predecessors and cover a wider range of conditions. This review of modern treatments is the most enlightening portion of Shrinks.

The battle between the traditionalists and the new wave of psychiatrists—exemplified in the adoption of the DSM coding system—takes up the last portion of the book. Lieberman was involved in the process, and as the president of the American Psychiatric Association, knew all the fine points being argued. Essentially discarding the entire psychoanalytic school took courage and a lot of political maneuvering. While the details of this struggle are significant to psychiatrists, the section could have been abridged for most readers.

In summary, the road from madhouses to modern treatment of mental illness has often been rocky, but it is well mapped in Shrinks by a psychiatrist who watched it evolve and helped push it forward. Lieberman doesn’t mind stepping on toes when needed, including a few of my old teachers and colleagues. ::
Dr. Bernstein, a Sebastopol neurologist, serves on the SCMA Editorial Board.